50 autopsies

[alaska82]

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I am hearing that the minimum number of autopsies that a resident should do would be reduced. Is this real or just a rumor?

 

[Autopsy Sweet]

I am hearing that the minimum number of autopsies that a resident should do would be reduced. Is this real or just a rumor?

All rumor. Dr. Bennett of ABP has said that won't happen, so until she's replaced (happening soon, right?) it won't be considered.

 

[KCShaw]

An internet discussion board is also a great place for definitive information and would never have anything to do with mere rumors. Heh.

The required number of autopsies discussion is probably one that will not completely end soon, even if the number itself doesn't change very often. Despite that, I haven't heard anything different recently.

 

[2121115]

I recently filled out a CAP survey about autopsies at my training program and it asked if I thought the current requirement of 50 was good or not. I guess maybe someone out there is contemplating it.

Of course I answered NO! The non-forensic "medical" autopsy is way over emphasized in residency. It is a vestige of times past.

Forensics is a different story though.

 

[Enkidu]

I recently filled out a CAP survey about autopsies at my training program and it asked if I thought the current requirement of 50 was good or not. I guess maybe someone out there is contemplating it.

Of course I answered NO! The non-forensic "medical" autopsy is way over emphasized in residency. It is a vestige of times past.

Forensics is a different story though.

But aren't medical autopsies useful for learning normal histology and seeing interesting conditions that aren't a normal part of surgpath?

 

[2121115]

But aren't medical autopsies useful for learning normal histology and seeing interesting conditions that aren't a normal part of surgpath?

Show me an autopsy where the supposed "normal" histology isn't blown to hell by autolysis or whatever. And half the time you can't even get immunos to work correctly on the tissue. Maybe you do see an "interesting" condition every now and then, but 90% of medical autopsies are straightforward MI's not some uber cool syndrome or what not.

Think about it. Over the residency time period you get 6 months of medical autopsy and 3 months of cytopath. What is more useful long term?

 

[Autopsy101]

The true medical autopsy request seems to be extinct at our hospital. Autopsies for the sake of medical education and scholarly pursuit regarding the natural history and pathologic progression of disease are essentially obsolete here. The residents I work with have little interest in them and view them as scutwork and a menial chore. Families rarely seem to request autopsies on patients for any reason other than medical-legal reasons anyway. The majority of the requests want toxicology testing for every drug that their loved one received because they are convinced that the death is due to deliberate drug overdose by the caregivers. We even have people wanting levels on drugs like colace and synthroid in patients with widely metastatic carcinoma. When I refuse those requests, then I am labeled as a conspirator with the hospital to cover everything up. It is a sad state of affairs for those of us with a true passion for the information that an interesting autopsy provides to pathologists, residents, families and clinicians.

 

[alaska82]

I did not find anything new that the clinicians are not aware of on autopsies.
I also do not find autopsy as a useful tool to improve grossing skills.
Histology is also not always good. And there is no need to do 50 autopsies to know histology and anatomy.

 

[pathstudent]

Autopsies at our academic hospital are down to less than 50% what they were in the 70s and 80s, but from what I hear from private practice people I talk to at the path society that they are like 5% what they were 20-30 years ago.

What I did like about the private practice medical autopsies is that they said they were focused and just performed to answer the clinician's question. I think it is a bit silly how weigh normal appearing adrenal glands and document benign simple cysts in the ovaries and such in our academic autopsies. Seriously, what's the point?

 

[deleted314957]

The true medical autopsy request seems to be extinct at our hospital. Autopsies for the sake of medical education and scholarly pursuit regarding the natural history and pathologic progression of disease are essentially obsolete here. The residents I work with have little interest in them and view them as scutwork and a menial chore. Families rarely seem to request autopsies on patients for any reason other than medical-legal reasons anyway. The majority of the requests want toxicology testing for every drug that their loved one received because they are convinced that the death is due to deliberate drug overdose by the caregivers. We even have people wanting levels on drugs like colace and synthroid in patients with widely metastatic carcinoma. When I refuse those requests, then I am labeled as a conspirator with the hospital to cover everything up. It is a sad state of affairs for those of us with a true passion for the information that an interesting autopsy provides to pathologists, residents, families and clinicians.

i make it clear that i only do autopsies as a service to, and at the request of the medical staff and that I don't do "private " autopsies. I then give a reference for a "private "autopsy. when they see it will cost $2500-$6000 they lose interest.

 

[KCShaw]

The best part about not doing an autopsy is that no-one ever knows how wrong (or right) the clinical assumptions, available history, conclusions drawn from imaging, conclusions drawn from laboratory tests, etc. were, nor what the effect of novel approaches were beyond the limitations of pre-mortem studies. To my knowledge I haven't seen a study which doesn't show that a significant proportion of autopsies reveal findings unknown to the decedent's clinical team, and that a proportion of those findings if known in life would have altered the course of treatment. There may be a subpopulation where that isn't the case.

That's not to say that every academic/hospital autopsy is appropriately managed given the individual circumstances, nor that weighing adrenal glands and identifying every parathyroid gland is inherently useful, either. Unfortunately most pathology attendings have either no concept of or no interest in focusing an autopsy, or doing an efficient job of examining things of import to that decedent, or all of the above. Combined with lack of compensation, for the most part, it doesn't exactly breed interest on the side of pathology, while on the side of non-path pre-mortem diagnostics there is a lot of marketing hype regarding what can be found and how great it all is. But not much about what it fails at or is unreliable at.

 

[HbyHA]

The residents I work with have little interest in them and view them as scutwork and a menial chore.

It is a sad state of affairs for those of us with a true passion for the information that an interesting autopsy provides to pathologists, residents, families and clinicians.

i'd say this is the prevailing attitude among most residents in my program. they seemed to take great pains in getting them as limited as possible (right lung, uterus, and left leg only was the most ridiculous i ever heard). It's hard to blame them when so many attendings see the autopsy as a waste of their time and a necessary evil one has to endure while working at an institution with a training program.

and it's gotten to the point were one can basically show up to the autopsy suite, glance over the organs, and put their name on the final report that the primary resident prepares and STILL get credit for the case. i do admit that it's hard to get your 50 otherwise, with the hospital rates next to non-existent. i got 5-0 cases, and that was after doing 2 months of FP in which i had an active role (eviscerating and/or cutting the organs) as opposed to many path residents who stand in the corner of the room practically sitting on their hands.

I did not find anything new that the clinicians are not aware of on autopsies.

i've shocked and amazed the clinicians at our monthly CPC-type conference a number of times. many cases have to do with the limitations of radiology (i'm not picking on that particular field). I had an SVC syndrome case that any 3rd med student could diagnose but the team wrote off because rads assured them that wasn't the case. never mind the 1 x 8" clot i found in the SVC/right atrium (oops we injected the radio-opaque dye into this guy's porta-cath that the clot formed around). i had a crazy case of PCP pneumonia that rads said HAD to be interstitial lung disease b/c this guy wasn't HIV/AIDS and being on low-dose steriods for 20 years couldn't possibly affect someone's immune system. and a guy with a belly full of blood from a ruptured liver capsule because his cirrhoto-mimetic HCC was below the resolution of CT scan.

i was sick of all the MIs/aspiration pneumonia/etc cases too, but you really can learn something from every case. no other field in medicine has the chance to be the ONLY people to figure out what really happened.

The best part about not doing an autopsy is that no-one ever knows how wrong (or right) the clinical assumptions, available history, conclusions drawn from imaging, conclusions drawn from laboratory tests, etc. were, nor what the effect of novel approaches were beyond the limitations of pre-mortem studies. To my knowledge I haven't seen a study which doesn't show that a significant proportion of autopsies reveal findings unknown to the decedent's clinical team, and that a proportion of those findings if known in life would have altered the course of treatment.

i whole heartedly agree. but what opinion do you expect from someone that does autopsies for a living?😀

 

[Ombret]

As a path resident, I have never minded autopsy per se, but the inefficiency of it kills me. I've thought about this over the years and have narrowed my bugaboos down to three:

1. We reconstruct painfully detailed mental maps of the patient's inpatient history, when a higher-level view would be more informative: patient with pneumonia, wound up septic. Also we focus 95% of our history-taking effort on the patient's final hospitalization even if their fate was sealed by their numerous previous MIs, or whatever.

2. Histology on every organ from every case. Takes time to cut in the sections, takes time for histology to process them (so this hurts them too, a little), takes time for attendings to sign them out.

3. In hospitals where I've been, autopsies are signed out by pathologists who are not very diagnostically confident OR are paralyzed by medicolegal concerns. Thus every follicular adenoma becomes a consult for the subspecialist.

It seems like the forensic pathologists cut the gordian knot on all of these issues. They have to, because they have to do six cases in one day. In my ME rotation I was just totally impressed with the efficiency of the system. On the other hand I know there was a lot of paperwork that the MEs had to deal with after sending the residents home. Am I right? And should hospital cases take a page out of the forensics book?

 

[Torsed]

Just think, the pathology boards are the only test in the world where at least 50 people have to die before you can qualify for it.

I can still see all their dead faces....just so I could click little boxes on a computer screen in Tampa and make Missus Dr. Bennett proud o' me! And make me do it all again in 10 years just to make sure I can still identify prostate cancer and gout histologically.

 

[2121115]

Ask yourself this....

If another medical autopsy never took place, what would the effect be? What would we be missing?

 

[HbyHA]

As a path resident, I have never minded autopsy per se, but the inefficiency of it kills me. I've thought about this over the years and have narrowed my bugaboos down to three:

1. We reconstruct painfully detailed mental maps of the patient's inpatient history, when a higher-level view would be more informative: patient with pneumonia, wound up septic. Also we focus 95% of our history-taking effort on the patient's final hospitalization even if their fate was sealed by their numerous previous MIs, or whatever.

2. Histology on every organ from every case. Takes time to cut in the sections, takes time for histology to process them (so this hurts them too, a little), takes time for attendings to sign them out.

3. In hospitals where I've been, autopsies are signed out by pathologists who are not very diagnostically confident OR are paralyzed by medicolegal concerns. Thus every follicular adenoma becomes a consult for the subspecialist.

It seems like the forensic pathologists cut the gordian knot on all of these issues. They have to, because they have to do six cases in one day. In my ME rotation I was just totally impressed with the efficiency of the system. On the other hand I know there was a lot of paperwork that the MEs had to deal with after sending the residents home. Am I right? And should hospital cases take a page out of the forensics book?

very true. where you trained sounds just like where i trained

we have cut a lot of the bs with many of the causes of death being relatively clear (GSW homicides, descent from height, etc). but in the wondrous land of the "Therapeutic Complication" and "Family Request", we still have a lot of the hospital type autopsies. this is very location dependent (ie i don't think anyone else has this). i love when residents rotating with us ask what we want histo on and ask "adrenal?" and the response is 'NOOOOOOOOOOOOOOOOOOO!"

 

[Circumflex]

I have to admit that as an FP fellow, therapeutic complications are not my favorite cases, but they can be very challenging and yield some unexpected findings. The whole point of the autopsy is to find out new information.

I would also say that pediatric autopsies are another story and that they can be very useful in many ways.

 

[KCShaw]

A lot has to do with knowing why you're doing the autopsy. In forensic path, we're primarily ruling in/out non-natural causes of death, then categorizing any proximate natural cause(s) without (for the most part) getting overly caught up in terminal mechanisms. We're guided by local laws as well as reasonably standardized practices. And many forensic cases involve younger decedents without extensive previous surgeries, adhesions, calcifications, MI's, strokes, infections, extensive ICU stays, etc. which would still have to be examined or the effects worked around and documented in some fashion.

There are so-called "hospital" autopsies, "forensic" autopsies, and "academic" autopsies. There's often no compelling reason that "forensic" and "hospital" autopsies need be terribly different -- a focus on the cause of death (and manner, primarily in forensic cases as others should expect to be natural) and any specific questions by the clinical team or family, without dissecting and microscopically examining every vein and nerve the decedent has. On the other hand, I think of "academic" autopsies with a purpose being research or teaching, where your goals can/should still be focused on an area of interest or teaching point.

Unfortunately most clinicians (much less family) don't understand what an autopsy can and cannot achieve. There are limitations, and in fact imaging or other studies, even history, are sometimes better at identifying certain things -- though worse at others. Clinicians expect what they expect from any other laboratory test, definitive answers to every one of their questions, even those they never asked. I think some path attendings get caught up in this discrepancy, just as some clinical physicians do, and try to put everything under the microscope and request absurd measurements, weights, proof of probe patency of things that almost certainly don't matter to that case, etc. Or they simply forget the purpose of that individual autopsy, if one was ever provided -- sometimes none is offered, family just request it through the hospital because they "want to know what happened", or clinicians request family to agree to one then they go off call and never inform you why they wanted one in the first place.

Believe me, I do understand some of the frustrations, and I think efficiency is one of the major issues -- a lot of time is spent counting individual leaves when understanding the lay of the forest may in fact be more useful to all involved.

That doesn't mean I think autopsies should be restricted to chest, head, whatever.. merely that there should be a reason to go above and beyond a given "standard" autopsy examination in any given case, and that that "standard" is probably what needs to be adjusted at any given institution.

 

[yaah]

i'd say this is the prevailing attitude among most residents in my program. they seemed to take great pains in getting them as limited as possible (right lung, uterus, and left leg only was the most ridiculous i ever heard).

We had a "pituitary only" autopsy once.

 

[lurksalot]

The best part about not doing an autopsy is that no-one ever knows how wrong (or right) the clinical assumptions, available history, conclusions drawn from imaging, conclusions drawn from laboratory tests, etc. were, nor what the effect of novel approaches were beyond the limitations of pre-mortem studies. To my knowledge I haven't seen a study which doesn't show that a significant proportion of autopsies reveal findings unknown to the decedent's clinical team, and that a proportion of those findings if known in life would have altered the course of treatment. There may be a subpopulation where that isn't the case.

That's not to say that every academic/hospital autopsy is appropriately managed given the individual circumstances, nor that weighing adrenal glands and identifying every parathyroid gland is inherently useful, either. Unfortunately most pathology attendings have either no concept of or no interest in focusing an autopsy, or doing an efficient job of examining things of import to that decedent, or all of the above. Combined with lack of compensation, for the most part, it doesn't exactly breed interest on the side of pathology, while on the side of non-path pre-mortem diagnostics there is a lot of marketing hype regarding what can be found and how great it all is. But not much about what it fails at or is unreliable at.

This.

 

[The right Path]

Has anyone read Diagnoses from the Dead by Richard Prayson? I thought it was a good book and offered a good rationale why autopsies are beneficial even outside forensic purposes.

 

[KCShaw]

Haven't, but I'm glad you pointed it out. I've seen a few things with his name on it, and I think I have a similar book "Autopsy: Learning from the Dead" around somewhere which to me has a startlingly similar title, enough to make me go "hmmm."

 

[deleted314957]

I am hearing that the minimum number of autopsies that a resident should do would be reduced. Is this real or just a rumor?

in community hospital pp an adult atupsy will be a rarity if you insist on no private autopsies or demand $4000 cash up-front, If the administration balks when the family complains you just tell them the family wants ammo for a lawsuit and you do not want to be in an adversial position between the medical staff and the hospital.that shuts them up. if the attending thinks he may turn a family request of 'curiosity: into a medical staff request of an autopsy, i always tell him/her that is the first thing the plaintiff attorney wants.

i have nothing against posts. i am a boarded forensic path with 4 years as a military and civilian ME. I just don't have the time to do something that is a waste of my time and sometimes sends me to court (where I REALLY make THEM PAY----$500/hr w/2 hr miimum and $350/hr thereafter. So the simplest subpoena costs $1000. Courts have never objected. Afterall, we have far moe education (and investment) than any $450/hr lawyer.

 

[zao275]

The recent autopsy survey from CAP started out as a request by many residents to lower the requirement. Since, as was stated above, Dr. Bennett seems pretty set on not allowing that (she retires in 2012 by the way), the Residents Forum Executive Committee decided to look into ways for residents to increase their numbers (to get their 50). Thus, we created a survey (since everyone loves a good survey, right?).

I actually saw some pretty interesting medical autopsies, but I agree that I was not fond of the time they took and the subsequent report. Fortunately (IMO), our autopsy attending was pretty paranoid about legal issues, and, thus, we didn't summarize the clinical course and we did not even provide cause of death. We just listed major findings and let the clinicians decide. Some might call that blasphemy, but it made our lives easier (compared to friends at more "thorough" institutions)!

 

[2121115]

We had to write exasperating reports. Describe every benign cell in the body, etc. Worthless waste of time, IMO. The more you put in a report, the more likely it is that it will contradict or can be construed to contradict something in some other medical record. This is why even surgpath microscopic description are going away, because there is just no reason to expose yourself by putting more words in the report. Autopsy should do the same.

 

[zao275]

We had to write exasperating reports. Describe every benign cell in the body, etc. Worthless waste of time, IMO. The more you put in a report, the more likely it is that it will contradict or can be construed to contradict something in some other medical record. This is why even surgpath microscopic description are going away, because there is just no reason to expose yourself by putting more words in the report. Autopsy should do the same.

Great point. But I am curious (maybe the forensics guys can answer this): what kind of legal risk does autopsy carry for us? My understanding is that you cannot be sued for malpractice (as it is a decedent, not technically a patient), although you can be sued for conspiring with the other doctors to cover things up and various other absurd reasons of that sort.

 

[2121115]

Great point. But I am curious (maybe the forensics guys can answer this): what kind of legal risk does autopsy carry for us? My understanding is that you cannot be sued for malpractice (as it is a decedent, not technically a patient), although you can be sued for conspiring with the other doctors to cover things up and various other absurd reasons of that sort.

I don't think it is a matter of us getting sued but the autopsy being used as fodder to sue a clinician. Lawyers love details and love to use words to trap people. If there is an autopsy with a meandering or careless microscopic description it falls under the "what you say can and will be used against you" category (or more likely used against someone else).

 

[The right Path]

Has anyone encountered the scenario as described above in their practice?

 

[KCShaw]

Not yet, personally anyway.

A lot of non-forensic pathologists are paranoid about ever being in the same room or on the same phone line as a lawyer, not to mention being deposed or called to testify on something. Hospital autopsies may occasionally be used in civil proceedings -- not often in criminal ones, but of course it's possible -- where I suspect competing experts are more likely to argue the case than the hospital pathologist is. A lot of times the crux of the case has to do with clinical treatment rather than the autopsy findings per se. But there is truth in saying that the more one writes, the more one is held accountable to. On the other hand, if you don't document it then the two sides can't agree to stipulate to the report and never call the pathologist. So I think there is also such a thing as not writing enough.

Some places require residents to write a clinico-pathologic correlation summarizing the clinical history and autopsy findings and how they might relate, but not necessarily include it in the autopsy report since it may be academic or simply speculative. I do think there is value in putting it together from a teaching point of view, especially these days when path residents do no clinical internship, though speculation beyond "reasonable degree of medical certainty" probably doesn't belong even in an academic autopsy report. But I understand it gets old when the only cases being done are 88 year olds with long protracted courses, multiple surgeries for multiple medical conditions, and simmered in the ICU for days to weeks prior to cardiac death. That's a problem of selection bias, so to speak, which is probably best addressed with clinicians.

 

[deleted314957]

Great point. But I am curious (maybe the forensics guys can answer this): what kind of legal risk does autopsy carry for us? My understanding is that you cannot be sued for malpractice (as it is a decedent, not technically a patient), although you can be sued for conspiring with the other doctors to cover things up and various other absurd reasons of that sort.

I will try to answer as an experienced FP whio is years removed from the field.
It is not so much "legal risk" as much as it is we (I) were trained to let the medical record speak for itself and, similarly, let the autopsy speak for itself. This most generally applied when one was doing a forensic autopsy on a decedent from an institutional setting. About the closest we would get to any discussion of the "medical record" in the autopsy was a paragraph detailing "evidence of medical therapy".
I ( and most of my cohort at that time 20 years ago) did not do any summary. The end of the post would say "the cause of death is pulmonary adenocarcinoma. the manner of death is natural" and that was it.

This approach left less "crap" for an atty in a civil suit to use to try to discredit you. If you have not re-hashed the patient's medical chart/progress notes (and perhaps rehashed them incorrectly with inaccuracies/ screwed up time sequences, etc) it just makes your life easier.

I think Dr. Alan Moritz, one of the true pioneers of American FP in the middle of the last century addressed this.

 

[Ruination]

show me an autopsy where the supposed "normal" histology isn't blown to hell by autolysis or whatever. And half the time you can't even get immunos to work correctly on the tissue. Maybe you do see an "interesting" condition every now and then, but 90% of medical autopsies are straightforward mi's not some uber cool syndrome or what not.

Think about it. Over the residency time period you get 6 months of medical autopsy and 3 months of cytopath. What is more useful long term?

qft.

 

[Circumflex]

At the end of the day, the cause and manner of death, as well as any findings in an autopsy report are opinions. Whether you are a FP or hospital pathologist, it is your opinion. You should have evidence to back it up, but lawyers can usually find someone with a different opinion.

 

[Autopsy101]

You should have evidence to back it up, but lawyers can usually find someone with a different opinion.

Totally agree! This concept was foreign to me when I graduated from residency, however, my experience has been exactly this.